Provider Demographics
NPI:1356476865
Name:REGENTS OF UNIVERSITY OF CALIFORNIA
Entity Type:Organization
Organization Name:REGENTS OF UNIVERSITY OF CALIFORNIA
Other - Org Name:UCLA DENTAL RADIOLOGY PRACTICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROFESSOR
Authorized Official - Prefix:DR
Authorized Official - First Name:STUART
Authorized Official - Middle Name:C
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:310-825-5634
Mailing Address - Street 1:10833 LE CONTE AVE
Mailing Address - Street 2:CHS 10 -165
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90095-1668
Mailing Address - Country:US
Mailing Address - Phone:310-825-5634
Mailing Address - Fax:310-206-2748
Practice Address - Street 1:10833 LE CONTE AVE
Practice Address - Street 2:CHS 10 -165
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095-1668
Practice Address - Country:US
Practice Address - Phone:310-825-5634
Practice Address - Fax:310-206-2748
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1223X0008X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0008XDental ProvidersDentistOral and Maxillofacial RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPENDINGMedicare ID - Type UnspecifiedDENTIST